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PERMITTEE NAME/ADDRESS (Include Faciliry NameJLacarion ijDiffereny
<br />NAME U(:H'~k CuS.L CO`FA!aY
<br />ADDRESSD .`t A - c it D
<br />45i'U"r.'t!
<br />C7 t)16317
<br />FACILJTY
<br />LOCATION A Y O t F+ C O 81 6 3 0
<br />ATTN: :.. bJ:; HSD~tN, :;£FIER+L MAkAGEB
<br />NATIONAL POLLl1TAM DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMR
<br />(7a B1 (t7~~B)
<br />CODU00"2
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM U TO y b J U
<br />(7773/ (74751 (767)) (1B-7B) (3f101)
<br />Forth Approved.
<br />i ~ U e' OMB No. 2040-0004
<br />Approval expires 06-31-96
<br />(5063 MA)
<br />F - FINAL ,:%UI'"[
<br />UI.iCIIAfiGE TO ThI9/FISH CHtF;K
<br />NOTE: Read Instructions before completing this form.
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<br />NAME/TITLE PRINCIPAL l7(ECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY ExAt11NED AND
<br />AND BASED ON MY
<br />IN TELEPHONE DATE
<br /> INQUIRY OF THOSE INDIVIDUAL S IMMEDIATELY RESPON ;
<br />SIBLE FOR OBTAINING
<br />Q IAIN L C k QS
<br />5 THE INFORMATION, I BELIEV E THE SUBMITTED IN FORMATION IS TRUE,
<br /> ACCURATE AND COMPLETE.
<br />PENALTIE
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<br />R I AM AWARE THAT TH
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<br />S POSSI8117rY OF FINE AND IMPRISONMENT. SEE 1B U.S.C. 11001 AND 33 U.S.C. SIGNATURE OF PRI IPAL IXECUTNE I
<br />TYPED OR P TED maHmuml~~N~ untlar mesa statutes may Inclutle /nes up ro 510,000 Ntl d
<br />p4smmam orbatwsen6months antl5 years.) OFFICER OR A ORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Aelerence ell attachments here)
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<br />EPA Form 3320.7 (OS-SS) Previous, editions may not be used. (REPLACES EPA FORM T-00 WHICH MAY NOT BE USED.) 00 01 4 / 9 9 0 51 3-114 0 PAGE 1 OF
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